Provider Demographics
NPI:1376728212
Name:MATHEWS, LACI R (CRNA)
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:R
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LACI
Other - Middle Name:R
Other - Last Name:PATTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 29TH AVE N STE 202
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1448
Mailing Address - Country:US
Mailing Address - Phone:615-327-4304
Mailing Address - Fax:615-327-7940
Practice Address - Street 1:110 29TH AVE N STE 202
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1448
Practice Address - Country:US
Practice Address - Phone:615-327-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN13027367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100030110Medicaid
AL009913624Medicaid
TN4171082OtherBCBS
TN3600186Medicaid
TN3600186Medicaid